Nursing Process in ER Documentation

  1. I'd like to hear from other ER nurses about how they ensure their documentation reflects the nursing process. In my research, it seems to be the best way to show that I have meet the "standard of care" and will help protect me in any future malpractice lawsuits.
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    About RN4HIRE

    Joined: Feb '07; Posts: 4


  3. by   JoshuaAdamsRN
    ADPIE - assessment, diagnosis, plan, intervention, evaluation. We have an initial systems flow sheet for assessment, and then a narrative note. On the narrative note, you address the elements of the nursing process. For example, this is exactly what my documentation on the narrative would look like for a patient having an asthma attack:

    1201: Nsg dx - impaired gas exchange. Pt to rm 4 by wheelchair. C/o sudden onset extreme SOB. Able to speak 2-3 words at a time. Room air SpO2 88%. Audible exp wheeze. Placed on cardiac monitor and O2 via NRB at 15 Lpm. MD aware of pt. arrival.
    1203: MD in to examine pt. SpO2 increased to 95%. Aerosol treatment ordered.
    1204: Albuterol/atrovent via neb. Portable CXR done.
    1208: SpO2 maintained at 96-98%

    And so on. So it addressed assessment and diagnosis, the plan is obvious, implementation steps, and evaluation (ongoing assessment).
  4. by   NurseJacqui
    Whatever happened to Airway Breathing and Circulation?